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Jun. 29th, 2022 11:56 pm![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
chuka_lisТолько часть из них обсуждается в статье. И все они, резонные.
How Abortion Bans Could Affect Care for Miscarriage and Infertility
Even before the Supreme Court ruling in Dobbs v Jackson Women's Health Organization was issued overturning Roe v Wade, restrictive state abortion laws had a chilling effect on management of patients with miscarriage because spontaneous abortions can be difficult to distinguish from induced abortions.
Now that more than half the states are expected to ban abortions or have already done so, clinicians who care for pregnant people and for people trying to become pregnant wonder how severe the ramifications will be for reproductive health care.
Experts question whether pregnant people in states with abortion bans will have to drive great distances, bleeding and in pain, to obtain care for miscarriage and whether clinicians who provide that care will encounter scrutiny from their licensing board and law enforcement. Infertility specialists aren’t certain whether they’ll be forced to transfer every embryo created in an in vitro fertilization cycle, thus risking high-order multiple pregnancies in their patients. And if a pregnancy doesn’t result after transfer of an embryo to a patient’s uterus, could that be viewed as an abortion?
These questions may seem implausible, but, as obstetrician-gynecologist Jennifer Villavicencio, MD, MPP, pointed out in a prepared statement, “laws like abortion restrictions and bans are not based in science or evidence, and therefore the language does not coincide within the practice of the highest-quality, evidence-based care.” Villavicencio, who has fellowship training in complex family planning, leads equity transformation at the American College of Obstetricians and Gynecologists (ACOG) and sees patients at a Washington, DC, Planned Parenthood clinic and at a Maryland hospital.
“I worry so much that instead of being able to dedicate all of my expertise, mental energy, and attention to treating my patient in front of me, I have to also think about whether or not I will face consequences, some criminal, for offering the most appropriate, individualized, and evidence-based care,” Villavicencio said in the statement, provided by ACOG.
The Court’s June 24 decision is “going to have a devastating effect on every aspect of a woman’s health care including if she is miscarrying,” ACOG President Iffath Abbasi Hoskins, MD, said at a press conference after the ruling.
Mismanaging Miscarriages?
Apparently, physicians in states with strict abortion laws already were thinking about the possible consequences of providing miscarriage care before Roe was overturned.
ACOG, in its practice bulletin on early pregnancy loss, defines miscarriage or early pregnancy loss as a “nonviable, intrauterine pregnancy with either an empty gestational sac or a gestational sac containing an embryo or fetus without fetal heart activity” within the first 12 weeks 6 days of gestation. Miscarriage occurs in 10% of all clinically recognized pregnancies, according to the practice bulletin, and can be treated by expectant management, medication, or surgical evacuation. Patients who don’t have medical complications or symptoms requiring urgent surgical evacuation of the nonviable pregnancy from the uterus can safely choose how they’d prefer to proceed, according to ACOG.
The issue is that the medications used to treat miscarriage, mifepristone and misoprostol, are the same as those used to induce a medication abortion, while surgical evacuation of the uterus is also performed for an incomplete medication abortion.
In an address to the nation shortly after the Court’s decision was announced, President Joe Biden pledged to protect the availability of these medications. Biden said he would direct the US Department of Health and Human Services (HHS) to act to ensure that these US Food and Drug Administration–approved medications are available “to the fullest extent possible.”
But it remains to be seen how potential HHS action might play out in clinical settings. “I’ve had people come to me because their doctor would not treat their miscarriage,” obstetrician-gynecologist Leah Torres, MD, medical director of the West Alabama Women’s Center in Tuscaloosa, 1 of 3 clinics in the state that had been providing abortion services before the Supreme Court overturned Roe, said in an interview.
Torres recently described such encounters in Slate. “I was angry that the patient’s doctor did not just provide the standard medical treatment for a miscarriage: surgically removing the contents of her uterus, which would stop her pain and bleeding,” she wrote. “Then I saw a different patient who was actively miscarrying, and a lightbulb clicked on: The doctors were afraid of being attacked by the state of Alabama.”
In May 2019, Republican Alabama Governor Kay Ivey signed into law House Bill 314, which made performing an abortion a Class A felony, punishable by at least 10 years and up to 99 years in prison. While a federal court blocked the state attorney general in November 2019 from enforcing the law, it went into effect when the Supreme Court overturned Roe.
“Any abortionist or abortion clinic operating in the State of Alabama in violation of Alabama law should immediately cease and desist operations,” Alabama Attorney General Steve Marshall said in a June 24 statement.
Torres’ practice was virtually entirely abortion care until the ruling, she said. “Now, overnight, I have been turned into a criminal.”
She has no plans to leave Alabama for a state where abortion is legal, though. “I’m going to provide the evidence-based medical care that is legal, and that includes miscarriage management.”
Torres moved from Salt Lake City to Alabama in 2020. She was excited about working as director of a clinic that provided abortion and planned to offer a range of other reproductive health and HIV care services.
Previously, “none of the clinics I worked in would let me have mifepristone for miscarriage management,” Torres explained. She said she’d be told, “well, yeah, it’s for abortion, too, so no.” And yet, both ACOG and the American Academy of Family Physicians note that research has shown that pretreatment with mifepristone followed by misoprostol of patients with first-trimester pregnancy loss resulted in a greater likelihood of successful management than treatment with misoprostol alone.
“Go Home”
Texas provided another early glimpse of potential implications for management of patients with miscarriage in states that ban abortion, Jacqueline Ayers, JD, senior vice president of the Planned Parenthood Federation of America, said June 9 in an online panel discussion sponsored by the Boston University School of Public Health.
In September, Texas enacted Senate Bill (SB) 8, which banned all abortions after detection of fetal cardiac activity, usually around 6 weeks’ gestation and often before people are aware they’re pregnant. As ACOG explains, SB 8 empowers any private citizen to file a civil suit against someone they claim has violated the law, whether or not they’re connected to the patient or are in the state of Texas. If the suit is successful, they are to receive an award of at least $10 000, plus attorneys’ fees.
“We’ve seen patients with intended pregnancies who aren’t able to get care after they have had complications with the pregnancy and the fetus is no longer viable, because doctors right now in the state of Texas are afraid to help,” Ayers said on the panel. “Those patients are being told, ‘go home and wait until you get sepsis and then come back…Go home until you might be facing death yourself.’” (If not treated quickly, by antibiotics and evacuation of the products of conception from the uterus, a septic miscarriage can be fatal.)
In a June 24 advisory, Texas Attorney General Ken Paxton noted that laws passed before Roe v Wade that prohibit abortion in Texas were still on the books. With Roe overturned, he wrote, “abortion providers could be criminally liable for providing abortions starting today.” And, he tweeted, “…today I’m closing my office—and making it an annual holiday—as a memorial to the 70 million lives lost bc of abortion.”
Family medicine physician Bhavik Kumar, MD, was born in London but grew up in Texas and returned to the state after completing his residency and fellowship in New York.
As medical director of Planned Parenthood Gulf Coast, with clinics in Greater Houston, New Orleans, and Baton Rouge, Louisiana, Kumar said he regularly sees patients seeking care who were turned away from an emergency department or physician’s office after an initial assessment suggested that they were miscarrying. “It’s not uncommon, it’s not surprising to see patients like this,” he said in an interview.
Sometimes someone at the patient’s first stop directed them to Kumar’s clinic and provided the phone number. Sometimes patients were left to figure out where to go. Kumar said the emergency departments and physicians’ offices probably decided, “I’m not going to touch it because it’s not worth it.”
Besides, as Torres had found, health care facilities other than abortion clinics tend to have a hands-off approach when it comes to mifepristone, Kumar said. The drug is approved only for medication abortions; miscarriage management is an off-label use.
Managing a miscarriage requires the same skills as providing medication and surgical abortions, Kumar noted. In a state like Texas, though, abortion training in residency programs is rare, he said. “How are they going to partner with an abortion clinic?”
The Accreditation Council for Graduate Medical Education requires that all obstetrics and gynecology training programs offer access to abortion training, but residents can choose to opt out of it. A recent study of all 286 accredited US obstetrics and gynecology residency programs found that 128 were in states certain or likely to ban abortion after Roe was overturned.
Is a Frozen Embryo a Person?
Pregnant people are not the only ones who could be affected by state abortion bans.
“…(W)hile the immediate target of these restrictions is abortion care, there is a clear and present danger that measures designed to restrict abortion could end up also curtailing access to the family building treatments upon which our infertility patients rely,” American Society for Reproductive Medicine (ASRM) President Marcelle Cedars, MD, said in a letter to members in May.
On the day the Dobbs decision was issued, Cedars released a statement noting that “the ability of physicians to treat their patients using the latest and best, evidence-guided practices and techniques should not be curtailed by elected officials or un-elected judges.”
The question, Cedars said in an interview, is whether states that ban abortion decide that human life, or “personhood,” begins as soon as sperm fertilizes an egg. In that case, the state might consider discarding embryos created via in vitro fertilization (IVF) to be an illegal abortion or even murder, she said.
“We know that some embryos don’t survive freezing and thawing,” Cedars, director of the Center for Reproductive Health at the University of California, San Francisco, noted. As she pointed out, “most fertilized eggs don’t make a baby.”
According to preliminary data, from the Society for Assisted Reproductive Technology (SART), 73 602 US neonates conceived with eggs fertilized in a laboratory were born in 2020, and increasing numbers of patients opted for elective single embryo transfer to reduce the risk of multiple births. Typically, the remaining embryos are frozen, possibly for transfer later.
“If they [states] do choose to come into the laboratory and restrict what they can do with embryos, it will be very difficult to practice safely with the best evidence we have,” Cedars said. “We’re kind of going backwards and taking everything we’ve learned to increase efficacy and decrease risk to the mother and the child and saying, ‘You can’t utilize those technologies.’”
According to Resolve, a national infertility advocacy organization, more than 100 personhood bills have been introduced in states ranging from Oregon to Florida and New Hampshire to Arizona and in Congress over the past decade. None have yet passed, but if they did, they could make IVF illegal, Resolve warns.
After Oklahoma Republican Governor Kevin Stitt on May 26 signed into law House Bill 4327, which banned abortion at any stage of gestation from fertilization onward, “the primal concern of patients [was]: Will we have access to IVF now?” Eli Reshef, MD, 1 of 4 board-certified infertility specialists in the state, said in an interview.
While the law “uses language about every stage of development and moment of conception, which can cause us concern…it also uses language [that] makes it clear it’s about a gestating pregnancy in a uterus. So our lawyers don’t think it applies to the in vitro-fertilized egg,” Sean Tipton, MA, ASRM chief advocacy, policy, and development officer, explained in an email.
“We’re not overly concerned,” Reshef, who has practiced in Oklahoma City for more than 30 years, said of the state’s infertility specialists. “Chicken Little I’m not.”
As soon as the Supreme Court overturned Roe, a 1910 Oklahoma trigger law banning abortion went into effect. But SB 612, passed this year, will become the primary abortion prohibition when it goes into effect on August 25, according to a press release from Stitt’s office.
“Nothing we do can be construed as an abortion,” said Reshef, a SART executive council member who has worked to thwart legislation that could limit IVF. “Those embryos are in a tank. It’s not gestation.”
Still, Reshef said, he is concerned that Oklahoma’s abortion ban will embolden supporters of personhood for fertilized eggs.
A bill that would have asked Oklahoma voters to decide whether to amend the state constitution to confer full personhood from the moment of conception carried over from the previous legislative session to the most recent session. The Senate passed it 36 to 9, but it did not come up for a vote in the House before the 2022 legislative session was adjourned at the end of May.
There’s always next year, of course, leaving Cedars to wonder: “Is this really about children or life, or is this about control?”
How Abortion Bans Could Affect Care for Miscarriage and Infertility
Even before the Supreme Court ruling in Dobbs v Jackson Women's Health Organization was issued overturning Roe v Wade, restrictive state abortion laws had a chilling effect on management of patients with miscarriage because spontaneous abortions can be difficult to distinguish from induced abortions.
Now that more than half the states are expected to ban abortions or have already done so, clinicians who care for pregnant people and for people trying to become pregnant wonder how severe the ramifications will be for reproductive health care.
Experts question whether pregnant people in states with abortion bans will have to drive great distances, bleeding and in pain, to obtain care for miscarriage and whether clinicians who provide that care will encounter scrutiny from their licensing board and law enforcement. Infertility specialists aren’t certain whether they’ll be forced to transfer every embryo created in an in vitro fertilization cycle, thus risking high-order multiple pregnancies in their patients. And if a pregnancy doesn’t result after transfer of an embryo to a patient’s uterus, could that be viewed as an abortion?
These questions may seem implausible, but, as obstetrician-gynecologist Jennifer Villavicencio, MD, MPP, pointed out in a prepared statement, “laws like abortion restrictions and bans are not based in science or evidence, and therefore the language does not coincide within the practice of the highest-quality, evidence-based care.” Villavicencio, who has fellowship training in complex family planning, leads equity transformation at the American College of Obstetricians and Gynecologists (ACOG) and sees patients at a Washington, DC, Planned Parenthood clinic and at a Maryland hospital.
“I worry so much that instead of being able to dedicate all of my expertise, mental energy, and attention to treating my patient in front of me, I have to also think about whether or not I will face consequences, some criminal, for offering the most appropriate, individualized, and evidence-based care,” Villavicencio said in the statement, provided by ACOG.
The Court’s June 24 decision is “going to have a devastating effect on every aspect of a woman’s health care including if she is miscarrying,” ACOG President Iffath Abbasi Hoskins, MD, said at a press conference after the ruling.
Mismanaging Miscarriages?
Apparently, physicians in states with strict abortion laws already were thinking about the possible consequences of providing miscarriage care before Roe was overturned.
ACOG, in its practice bulletin on early pregnancy loss, defines miscarriage or early pregnancy loss as a “nonviable, intrauterine pregnancy with either an empty gestational sac or a gestational sac containing an embryo or fetus without fetal heart activity” within the first 12 weeks 6 days of gestation. Miscarriage occurs in 10% of all clinically recognized pregnancies, according to the practice bulletin, and can be treated by expectant management, medication, or surgical evacuation. Patients who don’t have medical complications or symptoms requiring urgent surgical evacuation of the nonviable pregnancy from the uterus can safely choose how they’d prefer to proceed, according to ACOG.
The issue is that the medications used to treat miscarriage, mifepristone and misoprostol, are the same as those used to induce a medication abortion, while surgical evacuation of the uterus is also performed for an incomplete medication abortion.
In an address to the nation shortly after the Court’s decision was announced, President Joe Biden pledged to protect the availability of these medications. Biden said he would direct the US Department of Health and Human Services (HHS) to act to ensure that these US Food and Drug Administration–approved medications are available “to the fullest extent possible.”
But it remains to be seen how potential HHS action might play out in clinical settings. “I’ve had people come to me because their doctor would not treat their miscarriage,” obstetrician-gynecologist Leah Torres, MD, medical director of the West Alabama Women’s Center in Tuscaloosa, 1 of 3 clinics in the state that had been providing abortion services before the Supreme Court overturned Roe, said in an interview.
Torres recently described such encounters in Slate. “I was angry that the patient’s doctor did not just provide the standard medical treatment for a miscarriage: surgically removing the contents of her uterus, which would stop her pain and bleeding,” she wrote. “Then I saw a different patient who was actively miscarrying, and a lightbulb clicked on: The doctors were afraid of being attacked by the state of Alabama.”
In May 2019, Republican Alabama Governor Kay Ivey signed into law House Bill 314, which made performing an abortion a Class A felony, punishable by at least 10 years and up to 99 years in prison. While a federal court blocked the state attorney general in November 2019 from enforcing the law, it went into effect when the Supreme Court overturned Roe.
“Any abortionist or abortion clinic operating in the State of Alabama in violation of Alabama law should immediately cease and desist operations,” Alabama Attorney General Steve Marshall said in a June 24 statement.
Torres’ practice was virtually entirely abortion care until the ruling, she said. “Now, overnight, I have been turned into a criminal.”
She has no plans to leave Alabama for a state where abortion is legal, though. “I’m going to provide the evidence-based medical care that is legal, and that includes miscarriage management.”
Torres moved from Salt Lake City to Alabama in 2020. She was excited about working as director of a clinic that provided abortion and planned to offer a range of other reproductive health and HIV care services.
Previously, “none of the clinics I worked in would let me have mifepristone for miscarriage management,” Torres explained. She said she’d be told, “well, yeah, it’s for abortion, too, so no.” And yet, both ACOG and the American Academy of Family Physicians note that research has shown that pretreatment with mifepristone followed by misoprostol of patients with first-trimester pregnancy loss resulted in a greater likelihood of successful management than treatment with misoprostol alone.
“Go Home”
Texas provided another early glimpse of potential implications for management of patients with miscarriage in states that ban abortion, Jacqueline Ayers, JD, senior vice president of the Planned Parenthood Federation of America, said June 9 in an online panel discussion sponsored by the Boston University School of Public Health.
In September, Texas enacted Senate Bill (SB) 8, which banned all abortions after detection of fetal cardiac activity, usually around 6 weeks’ gestation and often before people are aware they’re pregnant. As ACOG explains, SB 8 empowers any private citizen to file a civil suit against someone they claim has violated the law, whether or not they’re connected to the patient or are in the state of Texas. If the suit is successful, they are to receive an award of at least $10 000, plus attorneys’ fees.
“We’ve seen patients with intended pregnancies who aren’t able to get care after they have had complications with the pregnancy and the fetus is no longer viable, because doctors right now in the state of Texas are afraid to help,” Ayers said on the panel. “Those patients are being told, ‘go home and wait until you get sepsis and then come back…Go home until you might be facing death yourself.’” (If not treated quickly, by antibiotics and evacuation of the products of conception from the uterus, a septic miscarriage can be fatal.)
In a June 24 advisory, Texas Attorney General Ken Paxton noted that laws passed before Roe v Wade that prohibit abortion in Texas were still on the books. With Roe overturned, he wrote, “abortion providers could be criminally liable for providing abortions starting today.” And, he tweeted, “…today I’m closing my office—and making it an annual holiday—as a memorial to the 70 million lives lost bc of abortion.”
Family medicine physician Bhavik Kumar, MD, was born in London but grew up in Texas and returned to the state after completing his residency and fellowship in New York.
As medical director of Planned Parenthood Gulf Coast, with clinics in Greater Houston, New Orleans, and Baton Rouge, Louisiana, Kumar said he regularly sees patients seeking care who were turned away from an emergency department or physician’s office after an initial assessment suggested that they were miscarrying. “It’s not uncommon, it’s not surprising to see patients like this,” he said in an interview.
Sometimes someone at the patient’s first stop directed them to Kumar’s clinic and provided the phone number. Sometimes patients were left to figure out where to go. Kumar said the emergency departments and physicians’ offices probably decided, “I’m not going to touch it because it’s not worth it.”
Besides, as Torres had found, health care facilities other than abortion clinics tend to have a hands-off approach when it comes to mifepristone, Kumar said. The drug is approved only for medication abortions; miscarriage management is an off-label use.
Managing a miscarriage requires the same skills as providing medication and surgical abortions, Kumar noted. In a state like Texas, though, abortion training in residency programs is rare, he said. “How are they going to partner with an abortion clinic?”
The Accreditation Council for Graduate Medical Education requires that all obstetrics and gynecology training programs offer access to abortion training, but residents can choose to opt out of it. A recent study of all 286 accredited US obstetrics and gynecology residency programs found that 128 were in states certain or likely to ban abortion after Roe was overturned.
Is a Frozen Embryo a Person?
Pregnant people are not the only ones who could be affected by state abortion bans.
“…(W)hile the immediate target of these restrictions is abortion care, there is a clear and present danger that measures designed to restrict abortion could end up also curtailing access to the family building treatments upon which our infertility patients rely,” American Society for Reproductive Medicine (ASRM) President Marcelle Cedars, MD, said in a letter to members in May.
On the day the Dobbs decision was issued, Cedars released a statement noting that “the ability of physicians to treat their patients using the latest and best, evidence-guided practices and techniques should not be curtailed by elected officials or un-elected judges.”
The question, Cedars said in an interview, is whether states that ban abortion decide that human life, or “personhood,” begins as soon as sperm fertilizes an egg. In that case, the state might consider discarding embryos created via in vitro fertilization (IVF) to be an illegal abortion or even murder, she said.
“We know that some embryos don’t survive freezing and thawing,” Cedars, director of the Center for Reproductive Health at the University of California, San Francisco, noted. As she pointed out, “most fertilized eggs don’t make a baby.”
According to preliminary data, from the Society for Assisted Reproductive Technology (SART), 73 602 US neonates conceived with eggs fertilized in a laboratory were born in 2020, and increasing numbers of patients opted for elective single embryo transfer to reduce the risk of multiple births. Typically, the remaining embryos are frozen, possibly for transfer later.
“If they [states] do choose to come into the laboratory and restrict what they can do with embryos, it will be very difficult to practice safely with the best evidence we have,” Cedars said. “We’re kind of going backwards and taking everything we’ve learned to increase efficacy and decrease risk to the mother and the child and saying, ‘You can’t utilize those technologies.’”
According to Resolve, a national infertility advocacy organization, more than 100 personhood bills have been introduced in states ranging from Oregon to Florida and New Hampshire to Arizona and in Congress over the past decade. None have yet passed, but if they did, they could make IVF illegal, Resolve warns.
After Oklahoma Republican Governor Kevin Stitt on May 26 signed into law House Bill 4327, which banned abortion at any stage of gestation from fertilization onward, “the primal concern of patients [was]: Will we have access to IVF now?” Eli Reshef, MD, 1 of 4 board-certified infertility specialists in the state, said in an interview.
While the law “uses language about every stage of development and moment of conception, which can cause us concern…it also uses language [that] makes it clear it’s about a gestating pregnancy in a uterus. So our lawyers don’t think it applies to the in vitro-fertilized egg,” Sean Tipton, MA, ASRM chief advocacy, policy, and development officer, explained in an email.
“We’re not overly concerned,” Reshef, who has practiced in Oklahoma City for more than 30 years, said of the state’s infertility specialists. “Chicken Little I’m not.”
As soon as the Supreme Court overturned Roe, a 1910 Oklahoma trigger law banning abortion went into effect. But SB 612, passed this year, will become the primary abortion prohibition when it goes into effect on August 25, according to a press release from Stitt’s office.
“Nothing we do can be construed as an abortion,” said Reshef, a SART executive council member who has worked to thwart legislation that could limit IVF. “Those embryos are in a tank. It’s not gestation.”
Still, Reshef said, he is concerned that Oklahoma’s abortion ban will embolden supporters of personhood for fertilized eggs.
A bill that would have asked Oklahoma voters to decide whether to amend the state constitution to confer full personhood from the moment of conception carried over from the previous legislative session to the most recent session. The Senate passed it 36 to 9, but it did not come up for a vote in the House before the 2022 legislative session was adjourned at the end of May.
There’s always next year, of course, leaving Cedars to wonder: “Is this really about children or life, or is this about control?”
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